Authorization to Release Medical Records

An "Authorization to Release Medical Records" is a vital legal document that grants healthcare providers the permission to disclose an individual's medical information to specified parties. This document plays a pivotal role in maintaining patient privacy and ensuring that sensitive medical details are only shared with individuals or organizations explicitly approved by the patient.

Hospital Generic 

Authorization to Release Medical Records 

Name of Patient ________________________________ Date(s) of Service ____________________    

Date of Birth ___________________ Social Security Number _______________________    

I, the undersigned, authorize the release of, or request access to the information specified below from the  medical record(s) of the above name patient. 

PATIENT INFORMATION IS NEEDED FOR:  

Continuing  Insurance  

Medical Care Military Social Security/Disability  

 Personal Use Other: _______________  Purposes School _____________________    

Legal  

INFORMATION TO BE RELEASED OR ACCESSED:  

History  

& Physical Consultation Report Emergency Room Record  

 Operative  

Reports Discharge/Death Summary Face Sheet  

 Lab/Path    

Reports X-Ray Reports/Images Other: ________________  

The above information may be released (specify name or title of the individual or the name of the organization to which  records are to be released and the appropriate address):  

TO:  

________________________________________________________________________________________________ (Doctor, Hospital, Attorney, Insurance Company, Self, etc.) Phone Number    

________________________________________________________________________________________________ Address (Street, City, State and ZIP)  

FROM:  

________________________________________________________________________________________________ (Doctor, Hospital, Attorney, Insurance Company, Self, etc.) Phone Number    

________________________________________________________________________________________________ Address (Street, City, State and ZIP)  

I understand that my records are confidential and cannot be disclosed without my written authorization, except when  otherwise permitted by law. Information used or disclosed pursuant to this authorization may be subject to re disclosure by the recipient and no longer protected. I understand that the specified information to be released may  include but is not limited to history, diagnoses, and/or treatment of drug or alcohol abuse, mental illness, or  communicable disease, including HIV and AIDS.  

I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in  reliance upon the authorization.  

The authorization will expire six (6) months from the date of my signature, unless I revoke the authorization prior to  that time.  

Date: __________________ Signature: _______________________________________________   Patient or Legally Authorized Representative    

 _______________________________________________  

Printed Name of Patient or Legally Authorized Representative  

____________________________________________________  

 Relationship to Patient